Historical Keynote
Addresses
Some
Observations on Epidemiology and Health Policy
“Prevention is primarily the
only effective method to reduce mortality and morbidity, but will have
only minimal effects on total health care costs,” concludes
Lewis Kuller (University of Pittsburgh), in an
epidemiological analysis of health policy in the US.
Why is this so?
Speaking at a symposium at Johns
Hopkins in honor of George Comstock’s 70th birthday,
Dr. Kuller suggested that the amount of disease in a population is
practically infinite; therefore, prevention is only likely to shift
services and costs from one medical problem to another.
Infinite Disease
Dr. Kuller noted several
examples in support of the observation that the supply of disease is
practically infinite. Thus, the prevalence of surgical treatment for
gallbladder disease varies substantially over time and over geographic
area, even though the prevalence of gallbladder disease identified at
post-mortem examination either as silent stones or prior
cholecystectomy is exceedingly high. Another example of this
phenomenon is the substantial increase of surgical treatment for
cartoid artery stenosis because of increased detection efforts with no
evidence of increase in the underlying prevalence of disease. The
identification of new diseases (e.g., AIDS) and redefinition of
symptomatology (e.g., Premenstrual Syndrome) also help to insure that
the supply of disease in the population remains high. Under these
circumstances, primary prevention is “unlikely to substantially
decrease utilization of services or health care costs.”
Implications
Acceptance of the “infinite
supply” hypothesis has important implications for epidemiologists in
how they perceive the role of prevention in health policy. It means
that prevention should not be sold as a means of reducing costs or
utilization of services. The prime determinants of health care costs
and utilization are related to methods of detection and treatment and
the modification of these will most likely come from government
manipulation of the health care delivery system or from increased
competition, not from changes in morbidity or mortality from any
specific disease.
Epidemiologist’s Role
Since prevention can make an
obvious impact on morbidity and mortality, it can be sold as a means
of improving the quality and length of life, and given an integral
role in health policy. According to Dr. Kuller, the best approach is
by a classification system based on our knowledge about the prevention
and treatment of specific diseases. Under this system, the staging
evolves from class 1 in which the specific etiology of a disease and
its treatment are unknown to class 7 which includes diseases which are
controlled primarily by environmental management. Many chronic
diseases are in class 1. The principal role of the epidemiologist
should be to better define the natural history and to search for risk
factors. As either treatment or etiology become better defined, the
epidemiologist may shift his or her research interest to such topics
as evaluation of early detection methods, clinical trials of specific
treatments, and modification of risk factors.
Other Tasks
As efforts are made to alter the
quantity of health care to reduce costs, it is possible these changes
will adversely effect health outcomes. Another important role for the
epidemiologist is monitoring morbidity and mortality in defined
populations to assess the extent of adverse effects, if any.
Conclusion
In his concluding remarks, Dr.
Kuller commented that, “It is important to recognize that successful
development of health policy requires good research and evaluation.
The community remains the unit of research. The proper collection of
data and its interpretation and application to preventive medicine and
health service delivery are the best approaches to improve both the
quality and quantity and modify the cost of health care without
adversely affecting the health status of the population. New words,
big dollars but fundamentally the same basic concepts that have worked
so well before.”
Published February
1985
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